Thrombophilia and anticoagulation in pregnancy: indications, risks and management

Considerations for Treating Nonobstetric Diseases in Pregnant Patients in the Emergency Department Setting

OBJECTIVE

To provide nonobstetric practitioners with an overview of key concepts for the pregnant patient and review treatment of 3 common acute nonobstetric diseases encountered in the emergency department setting.

DATA SOURCES

A literature search of PubMed was performed (1997-February 2023) using key search terms related to pregnancy, pain, urinary tract infection (UTI), venous thromboembolism (VTE), and anticoagulants.

STUDY SELECTION AND DATA EXTRACTION

Relevant articles in English and humans were considered.

DATA SYNTHESIS

When caring for a pregnant patient, it is important to utilize appropriate assessments, understand terms used in this population, and recognize how the physiological and pharmacokinetic changes that occur in pregnancy can influence medication use. Pain, UTIs, and VTE are common in this population. Acetaminophen is the most widely used medication for the management of pain during pregnancy and the drug of choice for mild pain in pregnancy not responsive to nonpharmacologic treatment. Pyelonephritis is the most common nonobstetric cause of hospitalization for pregnant patients. Antimicrobial treatment should consider maternal-fetal safety and local resistance patterns. Pregnant and postpartum patients have a 4- to 5-fold increased risk of developing a VTE compared with nonpregnant patients. Low-molecular-weight heparin is the preferred treatment.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Pregnant patients often seek acute care in the emergency department setting for nonobstetric needs. Pharmacists in this setting should understand appropriate assessment questions and terms used within this population, the basics of physiological and pharmacokinetic changes in pregnancy that can impact treatment, and which resources are best to utilize for drug information of the pregnant patient.

CONCLUSION

Practitioners in the acute care setting commonly encounter pregnant patients seeking care for nonobstetric concerns. This article covers key pregnancy-related information for the nonobstetric practitioner and focuses on the management of acute pain, UTI, and VTE during pregnancy.

Gestational diabetes mellitus is associated with antenatal hypercoagulability and hyperfibrinolysis: a case control study of Chinese women

BACKGROUND

To determine the relationship between gestational diabetes mellitus (GDM) and coagulation/fibrinolysis abnormality in antenatal Chinese women.

METHODS

Case control study: 50 women had GDM and 132 did not (the NGDM group) grouping by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. Maternal plasma biochemistry and previous medical history were collected from perinatal health records. Antenatal coagulation/fibrinolysis activity (CFA) parameters were assessed using thromboelastography and routine CFA parameters, respectively. Univariate and multiple regression analyses were used to evaluate the associations between GDM and CFA parameters. Maternal age, platelet, ALT, ALP, urea nitrogen, and previous history of abortion were taken as the covariables.

RESULTS

The women with GDM were significantly older than those without GDM (30.3 vs. 28.6 years, p = .012). Compared with the NGDM group, the GDM group had a significantly higher prevalence of cesarean delivery (56.0 vs. 37.9%, p = .027) and higher values of fibrinogen (FIB; 4.7 vs. 4.3 g/L, p = .001), activated partial thromboplastin time (APTT; 30.9 vs. 29.5 s, p = .010).There were no significant differences in the prevalence of maternal thrombotic events or neonatal events. GDM was significantly associated with higher APTT (β =1.41 s, 95% CI: 0.29-2.53), higher FIB (β = 0.38 g/L, 95% CI: 0.14-0.61), and higher percentage reduction in clot lysis after 30 min (LY30; β = 1.14%, 95% CI: 0.15-2.13) after adjustment for potential confounding factors.

CONCLUSIONS

GDM is significantly associated with hypercoagulability and hyperfibrinolysis in these antenatal Chinese women.

Comparison of 2 approaches in management of pregnant women with inherited trombophilias: Prospective analytical cohort study

Previous adverse pregnancy outcomes (APO) in women with hereditary thrombophilia have emerged as new indications for prophylactic use of low-molecular-weight heparin (LMWH) during pregnancy. Recent meta-analysis conducted to establish if LMWH may prevent recurrent placenta-mediated pregnancy complications point to important therapeutic effect but these findings are absolutely not universal. Furthermore, previous studies regarding LMWH prophylaxis for APO in women with inherited thrombophilia were performed in high risk patients with previous adverse health outcomes in medical, family and/or obstetric history. Therefore, the aim of this study was to investigate the effects of LMWH prophylaxis on pregnancy outcomes in women with inherited thrombophilias regardless of the presence of previous adverse health outcomes in medical, family, and obstetric history.Prospective analytical cohort study included all referred women with inherited thrombophilia between 11 and 15 weeks of gestation and followed-up to delivery. Patients were allocated in group with LWMH prophylaxis (study group) and control group without LWMH prophylaxis. The groups were compared for laboratory parameters and Doppler flows of umbilical artery at 28 to 30th, 32nd to 34th and 36th to 38th gestational weeks (gw), and for obstetric and perinatal outcomes.The study group included 221 women and control group included 137 women. Mean resistance index of the umbilical artery Ri in 28 to 30, 32 to 34, and 36 to 38 gw were significantly higher in the control group compared to study group (0.71 ± 0.02 vs 0.69 ± 0.02; 0.67 ± 0.03 vs 0.64 ± 0.02; and 0.67 ± 0.05 vs 0.54 ± 0.08, respectively). Intrauterine fetal death (IUFD) and miscarriages were statistically significantly more frequent in control group compared to the patients in study (P < .001). The frequencies of fetal growth restriction (FGR) and APO were significantly higher in the control group compared to the study group (P = .008 and P < .001, respectively). In a multivariate regression model with APO as a dependent variable, only Ri was detected as a significant protective factor for APO, after adjusting for age and LMWH prophylaxis (P < .001).We have demonstrated better perinatal outcomes in women with LMWH prophylaxis for APO compared to untreated women.